There are many causes of heel pain. One of the less familiar sources of injury to the heel is to the calcaneal fat pad. This injury can be mistaken for plantar fasciitis, but is a completely different entity.

What is it?
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Fat pad injury refers to damage or disruption of the calcaneal (heel) fat pad. This structure is approximately one inch thick and made up of fatty tissue enclosed by ligamentous baffles or chambers. The purpose of this uniquely designed structure is to absorb shock and cushion the heel bone.

If the fat pad is displaced or thins, then its ability to protect the heel bone from impact is decreased, which can result in heel pain.

What are the symptoms?

Fat pad injuries usually present as centralized heel pain that feels like a deep ache or bruise. You can recreate the symptoms by pressing down in the middle of the heel. Walking barefoot on hard surfaces is generally painful.

Plantar fasciitis differs from this presentation as it is felt more towards the instep and is more forward in position. Plantar fasciitis is usually a sharper pain than fat pad-associated pain.

Because of this laundry list of other ailments, you should visit to your friendly neighborhood health care provider when you develop heel pain to rule out these nastier conditions.

What are the causes/predisposing factors of this condition?

It appears there are two categories of fat pad injury: degenerative and traumatic.

Degenerative injuries refer to the thinning or atrophy of the fat pad. This loss of cushioning can lead to greater impact loads on the heel and subsequently, heel pain. Risk factors appear to be increased age and obesity.

Traumatic onset can be due to increased activity levels or a single sharp blow to the heel such as stepping on a stone.

Other risk factors include the presence a calcaneal bone spur and a history of corticosteroid injections in the heel.

Corticosteroid injections tend to thin the fat pad making it more susceptible to injury. This is important since some doctors use corticosteroid injections to treat plantar fasciitis.

What can be done to treat or prevent this injury?

When treating this condition, an obvious point is that no corticosteroid injections are used. If the doctor does inject the fat pad, it is with an anesthetic. Surgery is also contraindicated since it usually results in a poor outcome.

Conservative treatment consists of heel taping, using heel cups or a heel pad, icing the area after activity, using well-cushioned shoes, running on softer surfaces, using orthotics (if needed) and anti-inflammatory medication.

Some other treatments to consider would be laser, shockwave and ultrasound modalities.

Activity modification and reducing bodyweight, if overweight, are also indicated.

As with most running injuries, a sensible return to running as symptoms improve is a tried and true approach. Running through this injury is not recommended. I would suggest that water running and cycling would be appropriate cross training exercises since they are non-weight bearing.

David,
I have not come across your situation in my practice. However, that doesn’t mean that the achilles is not contributing to your heel pad problem. A common finding with achilles repairs is lots of scar tissue. This inhibits the foot from properly plantar flexing or dorsiflexing (pointing the toes up or down). Compare your good side with your bad side. If there is a loss of mobility on the bad side, there may be increased shock to the heel when running, this could cause your problem. Solution- aggressive soft tissue therapy directed at the scar tissue and foot and ankle mobilization, along with water running or cycling to let the heel rest.
Good Luck!

Thank you. I think I have this. I’ve had pain for 6 months which came after a calf cramp. I am unable to run. I also have a history of a sequestered disc which left a decrease sensation in the same foot. I don’t know if my heel pain is coming from sciatica or heel pad injury. There is very little information out there about heel pain, with the exception of plantar fasciitis.

I’ve tried all kinds of things, ultrasound, laser, heel inserts, orthotics, etc. Nothing seems to work long term. As of last night I deciced to tape my heel as a heel pad injury and see what happpens. If you have any other information on this topic, please let me know.

I have the same injury as you describe the fatty pad is badly bruised on the left leg only, I have had amazing help from my specialist. Mine has been from the achilles heel tendon and so the calf muscles being so over tight from a fall 3 years ago down some concrete steps which created a calf bone splint. As well as this as I am 46yrs old I have discovered my hormones have also been responsible for the changes in my lower tendons too, I also need to loose weight which I am doing slowly…

I have been wearing my proper shoes with orthotics and WonderZorbs on top of these when I am inside my house now constantly instead of bare feet, and of course the same when I go outside, my gym shoes are best outside. I get my calf muscles masages my my physio foot specialist weekly and ice my foot every day for half an hour. I have had this for 2 months now and it has been a nightmare I have been a cripple, but am now getting great results from paying attention to what I need to move forward with this now every day.

Great to read and understand my heel pain could be a calcaneal fat pad injury rather than the typical diagnosed plantar fasciitis….I have no arch pain at all. While training for my marathon, ran 18 mies on/off road and more than lkely stepped thru rocks/stones. I have heel pain / soreness but not sharp throbs, after running my short runs, using ice pack directly to heel helps significantly. Would you recommend running the marathon, it’s in two weeks and I”m tapering my runs now.
Thank you for any recommendation.
C

Hi Christine,
You may indeed have a fat pad injury or even a bone bruise on your heel. Both are nasty in that they tend to have a long lifespan. This is a close call on doing the marathon. Generally you want to be pain free by race day in order to avoid worsening or prolonging the condition. I wouldn’t want to run 10 miles with a sore foot let alone 26! Imagine what limping or changing your running form over this distance will do to the rest of your body! Use your best judgement- but being pain free is the best guide.

I have been unable to get any good advice on this from my sports medicine doctor and was so excited to find this thread with some recent posts.

I typically do a month long 850 km walk every spring. I have been doing this since I turned 50 in 2000. On one occasion, I had heel pain at the end and wound up in a walking cast for months with a diagnosis of tarsal tunnel; another time I had lesser pain and stayed off the heel for about 6 weeks — no diagnosis but cortisone shots helped. I’m not really sure what those injuries were but they eventually healed completely.

This past May I had to stop my walk about 350 km in because of heel pain. My heel was bright red, and the size and shape of the redness tracked the heel of my hard orthotic exactly. I was unable to see my sports medicine doctor until about three months later because I was out of the country, and by then the heel was fine. But based on my symptoms (particularly the fact that there was a pain around the edge of my heel noticeable when I pulled on my jeans), he agreed wtih my web research that I probably had an injury to my heel’s fat pad. He also said that given my age, I likely had some plantar fasciitis mixed in for good measure. My feet are fine now, I work out daily with no problem. But I’m nervous about my next walk.

I now have a pair of softer orthotics (kind of a styrofoam-y looking material), which I plan to use next spring when I try a longer 1000 km walk. I’m wondering what if anything I can do to try to avoid the same problem. Heel cups are not possible because of my need for the orthotic, and another sports person I saw said that heel cups may not be good anyway because they prevent the pad from doing its natural splaying.

My doctor suggested slowing down (my natural pace is about 6 km an hour) and making sure my rest stops are short. I also ice every night and typically take 8 200mg ibuprophen spread over the day (only when on these walks). I am also trying to stretch the achilles and plantar faschia every day in case that might help.

If anyone has recommendations or comments on what I’m doing now, or what I can do while walking, I would be so appreciative. I know this is a long post and I apologize for that but I really haven’t found anyone with a lot of knowledge about this fat pad problem.